Deficiencies in Coordination of Care for Patients with Treatment-Resistant Depression at the VA San Diego Healthcare System in California

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the request of Chairman Mark Takano, and Representatives Julia Brownley, Chris Pappas, and Mike Levin, members of the House Committee on Veterans’ Affairs, to evaluate allegations related to a lack of care coordination for patients receiving ketamine for treatment-resistant depression (depression that has failed to respond after multiple treatments) in the community after authorizations for the care lapsed in September 2019 at the VA San Diego Healthcare System (facility) in California. The OIG substantiated that the facility ended authorizations for community care for patients receiving ketamine, a medication used for treatment-resistant depression, in October 2019 and again in March 2020. The discontinuation negatively affected 35 patients during the two time frames. While distress related to uncertainties about continuing ketamine treatment were identified as a contributory stressor, the OIG did not substantiate that discontinuation of community care resulted in a patient’s death by suicide as the community provider continued to offer ketamine treatment to that patient. The OIG also identified deficiencies in facility processes. The OIG concluded that risks for negative patient outcomes increased due to • communication and care coordination deficits, • terminating community care authorizations, • accelerating timelines for care transition, • uncertainties from changing treatment for complex patients The OIG made two recommendations to the Under Secretary for Health regarding community care providers’ review of VA’s protocol for ordering ketamine and research related to the use of ketamine for treatment-resistant depression. Four recommendations were made to the Facility Director related to community care processes for coordination of non-VA care and ensuring coordinated, clinically informed plans for transitioning remaining patients to care at the facility.